Self-Reported Adherence to Antiretroviral Therapy (ART) Among Women Engaged in Commercial Sex Work in Southern Uganda.

We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW.

Examining Changes in Sleep Duration Associated with the Onset of the COVID-19 Pandemic: Who is Sleeping and Who is Not?

The COVID-19 pandemic has resulted in social isolation and reports of insomnia. However, reports of changes in sleep duration and associated factors are few. To determine the impact of COVID-19 on changes in sleep behavior, data were analyzed from an online survey of adults recruited via social media that included questions asking whether the respondent slept less or more after the onset of the pandemic as well as self-reported sociodemographic and occupational information; beliefs about COVID-19; and responses pertaining to loneliness, anxiety, and depression. There were 5,175 respondents; 53.9% had a change in sleep duration.17.1% slept less and 36.7% slept more. Sleeping more was related to greater education, being single/divorced/separated, unemployed or a student. Being retired, divorced/separated or a homemaker, and living in the Mountain or Central time zones were associated with less sleep. Beliefs that COVID-19 would result in personal adverse consequences was associated with both more and less sleep. However, the strongest associations for both more and less sleep were seen with depression, anxiety, and loneliness. In summary, changes in sleep duration since the start of the COVID-19 pandemic were highly prevalent among social media users and were associated with several sociodemographic factors and beliefs that COVID-19 would have adverse personal impacts. However, the strongest associations occurred with worse mental health suggesting that improvements may occur with better sleep.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.2002800 .

Universal healthcare coverage and health service delivery before and during the COVID-19 pandemic: A difference-in-difference study of childhood immunization coverage from 195 countries.

BACKGROUND: Several studies have indicated that universal health coverage (UHC) improves health service utilization and outcomes in countries. These studies, however, have primarily assessed UHC's peacetime impact, limiting our understanding of UHC's potential protective effects during public health crises such as the Coronavirus Disease 2019 (COVID-19) pandemic. We empirically explored whether countries' progress toward UHC is associated with differential COVID-19 impacts on childhood immunization coverage. METHODS AND FINDINGS: Using a quasi-experimental difference-in-difference (DiD) methodology, we quantified the relationship between UHC and childhood immunization coverage before and during the COVID-19 pandemic. The analysis considered 195 World Health Organization (WHO) member states and their ability to provision 12 out of 14 childhood vaccines between 2010 and 2020 as an outcome. We used the 2019 UHC Service Coverage Index (UHC SCI) to divide countries into a "high UHC index" group (UHC SCI ≥80) and the rest. All analyses included potential confounders including the calendar year, countries' income group per the World Bank classification, countries' geographical region as defined by WHO, and countries' preparedness for an epidemic/pandemic as represented by the Global Health Security Index 2019. For robustness, we replicated the analysis using a lower cutoff value of 50 for the UHC index. A total of 20,230 country-year observations were included in the study. The DiD estimators indicated that countries with a high UHC index (UHC SCI ≥80, n = 35) had a 2.70% smaller reduction in childhood immunization coverage during the pandemic year of 2020 as compared to the countries with UHC index less than 80 (DiD coefficient 2.70; 95% CI: 0.75, 4.65; p-value = 0.007). This relationship, however, became statistically nonsignificant at the lower cutoff value of UHC SCI <50 (n = 60). The study's primary limitation was scarce data availability, which restricted our ability to account for confounders and to test our hypothesis for other relevant outcomes. CONCLUSIONS: We observed that countries with greater progress toward UHC were associated with significantly smaller declines in childhood immunization coverage during the pandemic. This identified association may potentially provide support for the importance of UHC in building health system resilience. Our findings strongly suggest that policymakers should continue to advocate for achieving UHC in coming years.

"I expected little, although I learned a lot": perceived benefits of participating in HIV risk reduction sessions among women engaged in sex work in Uganda.

BACKGROUND: The global HIV burden remains a public health concern. Women engaged in sex work (WESW) are at higher risk of acquiring HIV compared to the general adult population. Uganda reports high rates of HIV prevalence among WESW. While WESW in Uganda have long been the subject of surveillance studies, they have not been targeted by theory-informed HIV prevention intervention approaches. In this study, we explored the perceived benefits of an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda. METHODS: As part of a larger randomized clinical trial, we conducted semi-structured in-depth interviews with 20 WESW selected using a stratified purposive sampling. All interviews were conducted in Luganda, language spoken in the study area, and audio-recorded. They were transcribed verbatim and translated to English. Thematic analysis was used to analyze the data. RESULTS: WESW's narratives focused on: (1) condom use; (2) alcohol/drug consumption; (3) PrEP use; (4) "handling" customers; and (5) "massaging" customers. WESW agreed that male condom was one of the important learning points for them and planned to continue using them while female condoms were received with mixed reactions. Many women appreciated receiving information about the risks of consuming alcohol and drugs, and discussed how they reduced/ eliminated their consumption. PrEP information was appreciated though identified by fewer WESW. Handling a client was discussed as a helpful strategy for safer sex through improved ability to convince customers to use condoms or avoiding sex. Massaging was also beneficial to avoid penetrative sex, but similar to female condom, massaging also yielded mixed perceptions. CONCLUSION: WESW found the intervention beneficial and described ways in which it improved their ability to engage in safer sex and stay healthy. The fact that WESW identified other strategies beyond condom use as helpful underlines the importance of adopting a comprehensive approach to behavioral interventions targeting HIV prevention even when combined with other interventions. Additionally, WESW's narratives suggest that incorporating the tenets of social cognitive theory and harm reduction approaches in HIV prevention among this population can result in risk behavior change.

Employment conditions as barriers to the adoption of COVID-19 mitigation measures: how the COVID-19 pandemic may be deepening health disparities among low-income earners and essential workers in the United States.

BACKGROUND: The COVID-19 pandemic has disproportionately impacted economically-disadvantaged populations in the United States (US). Precarious employment conditions may contribute to these disparities by impeding workers in such conditions from adopting COVID-19 mitigation measures to reduce infection risk. This study investigated the relationship between employment and economic conditions and the adoption of COVID-19 protective behaviors among US workers during the initial phase of the COVID-19 pandemic. METHODS: Employing a social media advertisement campaign, an online, self-administered survey was used to collect data from 2,845 working adults in April 2020. Hierarchical generalized linear models were performed to assess the differences in engagement with recommended protective behaviors based on employment and economic conditions, while controlling for knowledge and perceived threat of COVID-19, as would be predicted by the Health Belief Model (HBM). RESULTS: Essential workers had more precarious employment and economic conditions than non-essential workers: 67% had variable income; 30% did not have paid sick leave; 42% had lost income due to COVID-19, and 15% were food insecure. The adoption of protective behaviors was high in the sample: 77% of participants avoided leaving home, and 93% increased hand hygiene. Consistent with the HBM, COVID-19 knowledge scores and perceived threat were positively associated with engaging in all protective behaviors. However, after controlling for these, essential workers were 60% and 70% less likely than non-essential workers, who by the nature of their jobs cannot stay at home, to stay at home and increase hand hygiene, respectively. Similarly, participants who could not afford to quarantine were 50% less likely to avoid leaving home (AOR: 0.5; 95% CI: 0.4, 0.6) than those who could, whereas there were no significant differences concerning hand hygiene. CONCLUSIONS: Our findings are consistent with the accumulating evidence that the employment conditions of essential workers and other low-income earners are precarious, that they have experienced disproportionately higher rates of income loss during the initial phase of the COVID-19 pandemic and face significant barriers to adopting protective measures. Our findings underscore the importance and need of policy responses focusing on expanding social protection and benefits to prevent the further deepening of existing health disparities in the US.

What predicts people's belief in COVID-19 misinformation? A retrospective study using a nationwide online survey among adults residing in the United States.

BACKGROUND: Tackling infodemics with flooding misinformation is key to managing the COVID-19 pandemic. Yet only a few studies have attempted to understand the characteristics of the people who believe in misinformation. METHODS: Data was used from an online survey that was administered in April 2020 to 6518 English-speaking adult participants in the United States. We created binary variables to represent four misinformation categories related to COVID-19: general COVID-19-related, vaccine/anti-vaccine, COVID-19 as an act of bioterrorism, and mode of transmission. Using binary logistic regression and the LASSO regularization, we then identified the important predictors of belief in each type of misinformation. Nested vector bootstrapping approach was used to estimate the standard error of the LASSO coefficients. RESULTS: About 30% of our sample reported believing in at least one type of COVID-19-related misinformation. Belief in one type of misinformation was not strongly associated with belief in other types. We also identified 58 demographic and socioeconomic factors that predicted people's susceptibility to at least one type of COVID-19 misinformation. Different groups, characterized by distinct sets of predictors, were susceptible to different types of misinformation. There were 25 predictors for general COVID-19 misinformation, 42 for COVID-19 vaccine, 36 for COVID-19 as an act of bioterrorism, and 27 for mode of COVID-transmission. CONCLUSION: Our findings confirm the existence of groups with unique characteristics that believe in different types of COVID-19 misinformation. Findings are readily applicable by policymakers to inform careful targeting of misinformation mitigation strategies.

Increased alcohol use during the COVID-19 pandemic: The effect of mental health and age in a cross-sectional sample of social media users in the U.S.

The COVID-19 pandemic has triggered a public health crisis of unprecedented scale. Increased alcohol use has been extensively documented during other crises, particularly among persons with anxiety and depression. Despite COVID-19's differential impact by age, the association of age, mental health and alcohol use during the pandemic has not been explored. This study aimed to examine whether age modified the association of anxiety and depressive symptoms with alcohol use during the COVID-19 pandemic. Two online surveys were administered to U.S. adult social media users in March and April 2020. Generalized linear models were conducted in 2020 among 5850 respondents (52.9% female; 22.0% aged 18-39 years, 47.0% aged 40-59 years, and 31.0% aged ≥60 years) to examine if age modified the association of anxiety and depression symptomatology and alcohol use. Overall, 29% of respondents reported increased alcohol use. Adjusted odds ratios of reporting increased alcohol use were 1.41 (95% CI = 1.20-1.66) among respondents with anxiety symptoms and 1.64 (95% CI = 1.21-2.23) among those with depressive symptoms compared to those without such symptoms. Whereas respondents aged 18-39 years had the highest probability of reporting increased alcohol use, the probability of older persons (40-59 and ≥60 years) reporting increased drinking was much greater among those with symptoms of anxiety and depression, compared to those without symptoms. These findings warrant age-differentiated public health messaging on the risks of excessive alcohol use and scale-up of substance use services for middle-aged and older adults with symptoms of depression and anxiety.

Food insecurity among households with children during the COVID-19 pandemic: results from a study among social media users across the United States.

BACKGROUND: In the United States, approximately 11% of households were food insecure prior to the COVID-19 pandemic. The present study aims to describe the prevalence of food insecurity among adults and households with children living in the United States during the pandemic. METHODS: This study utilized social media as a recruitment platform to administer an original online survey on demographics and COVID-related food insecurity. The survey was disseminated through an advertisement campaign on Facebook and affiliated platforms. Food insecurity was assessed with a validated six-item United States Department of Agriculture (USDA) Household Food Security Survey Module, which was used to create a six-point numerical food security score, where a higher score indicates lower food security. Individual-level participant demographic information was also collected. Logistic regressions (low/very-low compared with high/marginal food security) were performed to generate adjusted odds ratios (AOR) and 95%CIs for food insecurity and select demographic characteristics. RESULTS: Advertisements reached 250,701 individuals and resulted in 5,606 complete surveys. Overall, 14.7% of participants self-identified as having low or very low food security in their households, with higher prevalence (17.5%) among households with children. Unemployment (AOR:1.76, 95%CI:1.09-2.80), high school or lower education (AOR:2.25, 95%CI:1.29-3.90), and low income (AOR[$30,000-$50,000]:5.87, 95%CI:3.35-10.37; AOR[< $30,000]:10.61, 95%CI:5.50-20.80) were associated with higher odds of food insecurity in multivariable models among households with children (and the whole sample). CONCLUSIONS: These data indicate exacerbation of food insecurity during the pandemic. The study will be instrumental in guiding additional research and time-sensitive interventions targeted towards vulnerable food insecure subgroups.

Severe Dengue Epidemic, Sri Lanka, 2017.

In 2017, a dengue epidemic of unexpected magnitude occurred in Sri Lanka. A total of 186,101 suspected cases and 440 dengue-related deaths occurred. We conducted a comprehensive analysis of this epidemic by comparing national surveillance data for 2017 with data from the preceding 5 years. In all Sri Lanka districts, dengue incidence in 2017 increased significantly over incidence during the previous 5 years. Older schoolchildren and young adults were more clinically symptomatic than those at extremes of age. Limited virologic surveillance showed the dominant circulating variant was dengue virus type 2 cosmopolitan genotype in the most affected district. One quarter of total annual cases were reported 5 weeks after the southwest monsoon started. Changes in vector abundance were not predictive of the increased incidence. Direct government expenditures on dengue control activities in 2017 were US $12.7 million. The lessons learned from this outbreak are useful for other tropical nations facing increasing dengue incidence.

Social media as a recruitment platform for a nationwide online survey of COVID-19 knowledge, beliefs, and practices in the United States: methodology and feasibility analysis.

BACKGROUND: The COVID-19 pandemic has evolved into one of the most impactful health crises in modern history, compelling researchers to explore innovative ways to efficiently collect public health data in a timely manner. Social media platforms have been explored as a research recruitment tool in other settings; however, their feasibility for collecting representative survey data during infectious disease epidemics remain unexplored. OBJECTIVES: This study has two aims 1) describe the methodology used to recruit a nationwide sample of adults residing in the United States (U.S.) to participate in a survey on COVID-19 knowledge, beliefs, and practices, and 2) outline the preliminary findings related to recruitment, challenges using social media as a recruitment platform, and strategies used to address these challenges. METHODS: An original web-based survey informed by evidence from past literature and validated scales was developed. A Facebook advertisement campaign was used to disseminate the link to an online Qualtrics survey between March 20-30, 2020. Two supplementary male-only and racial minority- targeted advertisements were created on the sixth and tenth day of recruitment, respectively, to address issues of disproportionate female- and White-oriented gender- and ethnic-skewing observed in the advertisement's reach and response trends. RESULTS: In total, 6602 participant responses were recorded with representation from all U.S. 50 states, the District of Columbia, and Puerto Rico. The advertisements cumulatively reached 236,017 individuals and resulted in 9609 clicks (4.07% reach). Total cost of the advertisement was $906, resulting in costs of $0.09 per click and $0.18 per full response (completed surveys). Implementation of the male-only advertisement improved the cumulative percentage of male respondents from approximately 20 to 40%. CONCLUSIONS: The social media advertisement campaign was an effective and efficient strategy to collect large scale, nationwide data on COVID-19 within a short time period. Although the proportion of men who completed the survey was lower than those who didn't, interventions to increase male responses and enhance representativeness were successful. These findings can inform future research on the use of social media recruitment for the rapid collection of survey data related to rapidly evolving health crises, such as COVID-19.

Reviewing estimates of the basic reproduction number for dengue, Zika and chikungunya across global climate zones.

BACKGROUND: Globally, dengue, Zika virus, and chikungunya are important viral mosquito-borne diseases that infect millions of people annually. Their geographic range includes not only tropical areas but also sub-tropical and temperate zones such as Japan and Italy. The relative severity of these arboviral disease outbreaks can vary depending on the setting. In this study we explore variation in the epidemiologic potential of outbreaks amongst these climatic zones and arboviruses in order to elucidate potential reasons behind such differences. METHODOLOGY: We reviewed the peer-reviewed literature (PubMed) to obtain basic reproduction number (R0) estimates for dengue, Zika virus, and chikungunya from tropical, sub-tropical and temperate regions. We also computed R0 estimates for temperate and sub-tropical climate zones, based on the outbreak curves in the initial outbreak phase. Lastly we compared these estimates across climate zones, defined by latitude. RESULTS: Of 2115 studies, we reviewed the full text of 128 studies and included 65 studies in our analysis. Our results suggest that the R0 of an arboviral outbreak depends on climate zone, with lower R0 estimates, on average, in temperate zones (R0 = 2.03) compared to tropical (R0 = 3.44) and sub-tropical zones (R0 = 10.29). The variation in R0 was considerable, ranging from 0.16 to 65. The largest R0 was for dengue (65) and was estimated by the Ross-Macdonald model in the tropical zone, whereas the smallest R0 (0.16) was for Zika virus and was estimated statistically from an outbreak curve in the sub-tropical zone. CONCLUSIONS: The results indicate climate zone to be an important determinant of the basic reproduction number, R0, for dengue, Zika virus, and chikungunya. The role of other factors as determinants of R0, such as methods, environmental and social conditions, and disease control, should be further investigated. The results suggest that R0 may increase in temperate regions in response to global warming, and highlight the increasing need for strengthening preparedness and control activities.

Using Big Data to Monitor the Introduction and Spread of Chikungunya, Europe, 2017.

With regard to fully harvesting the potential of big data, public health lags behind other fields. To determine this potential, we applied big data (air passenger volume from international areas with active chikungunya transmission, Twitter data, and vectorial capacity estimates of Aedes albopictus mosquitoes) to the 2017 chikungunya outbreaks in Europe to assess the risks for virus transmission, virus importation, and short-range dispersion from the outbreak foci. We found that indicators based on voluminous and velocious data can help identify virus dispersion from outbreak foci and that vector abundance and vectorial capacity estimates can provide information on local climate suitability for mosquitoborne outbreaks. In contrast, more established indicators based on Wikipedia and Google Trends search strings were less timely. We found that a combination of novel and disparate datasets can be used in real time to prevent and control emerging and reemerging infectious diseases.

A combination intervention addressing sexual risk-taking behaviors among vulnerable women in Uganda: study protocol for a cluster randomized clinical trial.

BACKGROUND: Sub-Saharan Africa (SSA) has the highest number of people living with HIV/AIDS, with Nigeria, South Africa, and Uganda accounting for 48% of new infections. A systematic review of the HIV burden among women engaged in sex work (WESW) in 50 low- and middle-income countries found that they had increased odds of HIV infection relative to the general female population. Social structural factors, such as the sex work environment, violence, stigma, cultural issues, and criminalization of sex work are critical in shaping sexually transmitted infection (STI)/HIV risks among WESW and their clients in Uganda. Poverty is the most commonly cited reason for involvement in sex work in SSA. Against this backdrop, this study protocol describes a randomized controlled trial (RCT) that tests the impact of adding economic empowerment to traditional HIV risk reduction (HIVRR) to reduce new incidence of STIs and HIV among WESW in Rakai and the greater Masaka regions in Uganda. METHODS: This three-arm RCT will evaluate the efficacy of adding savings, financial literacy and vocational training/mentorship to traditional HIVRR on reducing new incidence of STI infections among 990 WESW across 33 hotspots. The three arms (n = 330 each) are: 1) Control group: only HIVRR versus 2) Treatment group 1: HIVRR plus Savings plus Financial Literacy (HIVRR + S + FL); and 3) Treatment group 2: HIVRR plus S plus FL plus Vocational Skills Training and Mentorship (V) (HIVRR + S + FL + V). Data will be collected at baseline (pre-test), 6, 12, 18 and 24-months post-intervention initiation. This study will use an embedded experimental mixed methods design where qualitative data will be collected post-intervention across all conditions to explore participant experiences. DISCUSSION: When WESW have access to more capital and/or alternative forms of employment and start earning formal income outside of sex work, they may be better able to improve their skills and employability for professional advancement, thereby reducing their STI/HIV risk. The study findings may advance our understanding of how best to implement gender-specific HIV prevention globally, engaging women across the HIV treatment cascade. Further, results will provide evidence for the intervention's efficacy to reduce STIs and inform implementation sustainability, including costs and cost-effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov , ID: NCT03583541 .

Economic cost and quality of life of family caregivers of schizophrenic patients attending psychiatric hospitals in Ghana.

BACKGROUND: Low and middle income countries face many challenges in meeting their populations' mental health care needs. Though family caregiving is crucial to the management of severe mental health disabilities, such as schizophrenia, the economic costs borne by family caregivers often go unnoticed. In this study, we estimated the household economic costs of schizophrenia and quality of life of family caregivers in Ghana. METHODS: We used a cost of illness analysis approach. Quality of life (QoL) was assessed using the abridged WHO Quality of Life (WHOQOL-BREF) tool. Cross-sectional data were collected from 442 caregivers of patients diagnosed with schizophrenia at least six months prior to the study and who received consultation in any of the three psychiatric hospitals in Ghana. Economic costs were categorized as direct costs (including medical and non-medical costs of seeking care), indirect costs (productivity losses to caregivers) and intangible costs (non-monetary costs such as stigma and pain). Direct costs included costs of medical supplies, consultations, and travel. Indirect costs were estimated as value of productive time lost (in hours) to primary caregivers. Intangible costs were assessed using the Zarit Burden Interview (ZBI). We employed multiple regression models to assess the covariates of costs, caregiver burden, and QoL. RESULTS: Total monthly cost to caregivers was US$ 273.28, on average. Key drivers of direct costs were medications (50%) and transportation (27%). Direct costs per caregiver represented 31% of the reported monthly earnings. Mean caregiver burden (measured by the ZBI) was 16.95 on a scale of 0-48, with 49% of caregivers reporting high burden. Mean QoL of caregivers was 28.2 (range: 19.6-34.8) out of 100. Better educated caregivers reported lower indirect costs and better QoL. Caregivers with higher severity of depression, anxiety and stress reported higher caregiver burden and lower QoL. Males reported better QoL. CONCLUSIONS: These findings highlight the high household burden of caregiving for people living with schizophrenia in low income settings. Results underscore the need for policies and programs to support caregivers.

Complexity and dynamism from an urban health perspective: a rationale for a system dynamics approach.

In a variety of urban health frameworks, cities are conceptualized as complex and dynamic yet commonly used epidemiological methods have failed to address this complexity and dynamism head on due to their narrow problem definitions and linear analytical representations. Scholars from a variety of disciplines have also long conceptualized cities as systems, but few have modeled urban health issues as problems within a system. Systems thinking in general and system dynamics in particular are relatively new approaches in public health, but ones that hold immense promise as methodologies to model and analyze the complexity underlying urban processes to effectively inform policy actions in dynamic environments. This conceptual essay reviews the utility of applying the concepts, principles, and methods of systems thinking to the study of complex urban health phenomena as a complementary approach to standard epidemiological methods using specific examples and provides recommendations on how to better incorporate systems thinking methods in urban health research and practice.

Modeling tools for dengue risk mapping - a systematic review.

INTRODUCTION: The global spread and the increased frequency and magnitude of epidemic dengue in the last 50 years underscore the urgent need for effective tools for surveillance, prevention, and control. This review aims at providing a systematic overview of what predictors are critical and which spatial and spatio-temporal modeling approaches are useful in generating risk maps for dengue. METHODS: A systematic search was undertaken, using the PubMed, Web of Science, WHOLIS, Centers for Disease Control and Prevention (CDC) and OvidSP databases for published citations, without language or time restrictions. A manual search of the titles and abstracts was carried out using predefined criteria, notably the inclusion of dengue cases. Data were extracted for pre-identified variables, including the type of predictors and the type of modeling approach used for risk mapping. RESULTS: A wide variety of both predictors and modeling approaches was used to create dengue risk maps. No specific patterns could be identified in the combination of predictors or models across studies. The most important and commonly used predictors for the category of demographic and socio-economic variables were age, gender, education, housing conditions and level of income. Among environmental variables, precipitation and air temperature were often significant predictors. Remote sensing provided a source of varied land cover data that could act as a proxy for other predictor categories. Descriptive maps showing dengue case hotspots were useful for identifying high-risk areas. Predictive maps based on more complex methodology facilitated advanced data analysis and visualization, but their applicability in public health contexts remains to be established. CONCLUSIONS: The majority of available dengue risk maps was descriptive and based on retrospective data. Availability of resources, feasibility of acquisition, quality of data, alongside available technical expertise, determines the accuracy of dengue risk maps and their applicability to the field of public health. A large number of unknowns, including effective entomological predictors, genetic diversity of circulating viruses, population serological profile, and human mobility, continue to pose challenges and to limit the ability to produce accurate and effective risk maps, and fail to support the development of early warning systems.

Childhood Violence, High School Academic Environment, and Adult Alcohol Use Among Latinas and Black Women: A Structural Equation Modeling Study.

OBJECTIVE: Young Latinas and Black women drink less than women of other racial/ethnic groups but experience more alcohol-related problems in midlife. This study aims to identify modifiable factors to prevent adult onset of alcohol use disorder (AUD) in this population. METHODS: Data were collected at six time points as part of the Harlem Longitudinal Development Study from 365 Latinas (47%) and Black (53%) women (mean age at time 1 = 14, standard deviation 1.3). Structural equation modeling was used to test hypothesized pathways from childhood physical and sexual abuse to AUD via depressive mood, anxiety disorders, and somatic complaints in the 20s. We also tested the moderation effect of the high school academic environment by including in the structural equation model two latent variable interaction terms between the school environment and each of the abuse variables. RESULTS: Childhood physical and sexual abuse was positively associated with depressive mood, anxiety disorders, and somatic complaints when participants were in the 20s. Depressive mood mediated childhood abuse and AUD when women were in the 30s. The high school academic environment attenuated the effect of physical, but not sexual abuse, on depressive mood (ß = -0.59, B = -9.38, 95% CI [-14.00, -4.76]), anxiety symptoms (ß = -0.61, B = -14.19, 95% CI [-21.76, -6.61]), appetite loss (ß = -0.41, B = -10.52, 95% CI [-15.61, -5.42]), and sleeplessness (ß = -0.50, B = -9.56, 95% CI [-13.95, -5.17]) in the early 20s. CONCLUSIONS: Our findings underscore the need to invest in early violence prevention interventions and in education to ensure equitable access to quality, academically oriented, and safe schools.

The synergistic impact of Universal Health Coverage and Global Health Security on health service delivery during the Coronavirus Disease-19 pandemic: A difference-in-difference study of childhood immunization coverage from 192 countries.

Universal Health Coverage (UHC) and Global Health Security (GHS) are two high-priority global health agendas that seek to foster health system resilience against health emergencies. Many countries have had to prioritize one agenda over the other due to scarce resources and political pressures. To aid policymakers' decision-making, this study investigated the individual and synergistic effects of countries' UHC and GHS capacities in safeguarding essential health service delivery during the COVID-19 pandemic. We used a quasi-experimental difference-in-difference methodology to quantify the relationship between 192 countries' progress towards UHC and GHS and those countries' abilities to provide 12 essential childhood immunization services between 2015 and 2021. We used the 2019 UHC Service Coverage Index (SCI) to divide countries into a "high UHC group" (UHC SCI≥75) and the rest (UHC SCI 75), and similarly used the 2019 GHS Index (GHSI) to divide countries into a "high GHS group" (GHSI≥65) and the rest (GHSI<65). All analyses were adjusted for potential confounders. Countries with high UHC scores prevented a 1.14% (95% CI: 0.39%, 1.90%) reduction in immunization coverage across 2020 and 2021 whereas countries with high GHSI scores prevented a 1.10% (95% CI: 0.57%, 1.63%) reduction in immunization coverage over the same time period. The stratified DiD models showed that across both years, high UHC capacity needed to be augmented with high GHS capacity to prevent a decline in immunization coverage while high GHS alone was able to safeguard immunization coverage. This study found that greater progress towards both UHC and GHS capacities safeguarded essential health service delivery during the pandemic but only progress towards GHS capacity was both a necessary and likely sufficient element for yielding this protective effect. Our results call for strategic investments into both health agendas and future research into possible synergistic effects of the two health agendas.

A pre-post evaluation study of a social media-based COVID-19 communication campaign to improve attitudes and behaviors toward COVID-19 vaccination in Tanzania.

In Tanzania, the One by One: Target COVID-19 campaign was launched nationally in July 2022 to address the prevalent vaccine hesitancy and lack of confidence in COVID-19 vaccines. The campaign mobilized social media influencers and viral content with the ultimate goal of increasing COVID-19 vaccine uptake in the country. The objective of this study was to empirically assess the impact of the campaign on three outcomes: vaccine confidence, vaccine hesitancy, and vaccination status. Using programmatic data collected through an online survey before and after the campaign, we conducted a difference-in-difference (DiD) analysis and performed a crude, adjusted, and propensity score-matched analysis for each study outcome. Lastly, to observe whether there was any differential impact of the campaign across age groups, we repeated the analyses on age-stratified subgroups. Data included 5,804 survey responses, with 3,442 and 2,362 responses collected before and after the campaign, respectively. Although there was only weak evidence of increased COVID-19 vaccine confidence in the campaign-exposed group compared to the control group across all age groups, we observed a differential impact among different age groups. While no significant change was observed among young adults aged 18-24 years, the campaign exposure led to a statistically significant increase in vaccine confidence (weighted/adjusted DiD coefficient = 0.76; 95% CI: 0.06, 1.5; p-value = 0.034) and vaccination uptake (weighted/adjusted DiD coefficient = 1.69.; 95% CI: 1.02, 2.81; p-value = 0.023) among young adults aged 25-34 years. Among adults aged 35 years and above, the campaign exposure led to a significant decrease in vaccine hesitancy (weighted/adjusted DiD coefficient = -15; 95% CI: -21, -8.3; p-value<0.001). The social media campaign successfully improved vaccine hesitancy, confidence, and uptake in the Tanzanian population, albeit to varying degrees across age groups. Our study provides valuable insights for the planning and evaluation of similar social media communication campaigns aiming to bolster vaccination efforts.

Understanding COVID-19 vaccine hesitancy in Meghalaya, India: Multiple correspondence and agglomerative hierarchical cluster analyses.

Meghalaya, a state in the northeastern region of India, had a markedly low vaccine uptake compared to the other states in the country when COVID-19 vaccines were being rolled out in 2021. This study aimed to characterize the distinct vaccine-hesitant subpopulations in healthcare and community settings in Meghalaya state in the early days of the vaccination program. We used data from a cross-sectional survey that was administered to 200 healthcare workers (HCWs) and 200 community members, who were a priori identified as 'vaccine-eligible' and 'vaccine-hesitant,' in Shillong city, Meghalaya, in May 2021. The questionnaire collected information on participants' sociodemographic characteristics, COVID-19 history, and presence of medical comorbidities. Participants were also asked to provide a dichotomous answer to a set of 19 questions, probing the reasons for their hesitancy towards COVID-19 vaccines. A multiple correspondence analysis, followed by an agglomerative hierarchical cluster analysis, was performed to identify the distinct clusters of vaccine-hesitant participants. We identified seven clusters: indecisive HCWs (n = 71), HCWs skeptical of COVID-19 and COVID-19 vaccines (n = 128), highly educated male tribal/clan leaders concerned about infertility and future pregnancies (n = 14), less educated adults influenced by leaders and family (n = 47), older adults worried about vaccine safety (n = 76), middle-aged adults without young children (n = 56), and highly educated ethnic/religious minorities with misinformation (n = 8). Across all the clusters, perceived logistical challenges associated with receiving the vaccine was identified as a common factor contributing to vaccine hesitancy. Our study findings provide valuable insights for local and state health authorities to effectively target distinct subgroups of vaccine-hesitant populations with tailored health messaging, and also call for a comprehensive approach to address the common drivers of vaccine hesitancy in communities with low vaccination rates.